Free CCDS Sepsis Criteria and Documentation (Sepsis-3) Questions and Answers 1 — Questions and Answers
Question 1: According to the Sepsis-3 consensus definition, sepsis is best described as:
- The presence of two or more Systemic Inflammatory Response Syndrome (SIRS) criteria.
- A positive blood culture in a febrile patient.
- Life-threatening organ dysfunction caused by a dysregulated host response to infection. (Correct answer)
- Bacteremia leading to hypotension.
Correct answer: Life-threatening organ dysfunction caused by a dysregulated host response to infection.
Sepsis-3 defines sepsis as a life-threatening organ dysfunction caused by a dysregulated host response to infection. This definition shifts the focus from inflammation (SIRS) to the life-threatening nature of the body's response.
Question 2: Which of the following clinical findings is a component of the quick Sequential Organ Failure Assessment (qSOFA) score?
- Heart rate > 100 bpm
- Altered mental status (Correct answer)
- Serum lactate > 2 mmol/L
- White blood cell count > 12,000/mm³
Correct answer: Altered mental status
The qSOFA score is a bedside tool to identify patients with suspected infection who are at greater risk for a poor outcome. Its three components are respiratory rate ≥ 22/min, altered mental status (GCS < 15), and systolic blood pressure ≤ 100 mm Hg.
Question 3: The Sepsis-3 definition of septic shock requires persisting hypotension needing vasopressors to maintain a MAP ≥ 65 mm Hg and what other finding?
- A qSOFA score of 3
- A documented positive blood culture
- A serum lactate level > 2 mmol/L after fluid resuscitation (Correct answer)
- Acute kidney injury with oliguria
Correct answer: A serum lactate level > 2 mmol/L after fluid resuscitation
Septic shock is a subset of sepsis with profound circulatory, cellular, and metabolic abnormalities. It is identified by the need for vasopressors for hypotension and a serum lactate level > 2 mmol/L despite adequate fluid resuscitation.
Question 4: A physician documents 'sepsis due to pneumonia' and 'acute kidney injury' in separate parts of the record. For coding purposes, what is required to link the AKI to the sepsis?
- No further documentation is needed as the link is implied.
- The lab values for creatinine must meet a specific threshold.
- A positive urine culture must be present.
- Explicit provider documentation linking the two conditions. (Correct answer)
Correct answer: Explicit provider documentation linking the two conditions.
Official coding guidelines require the provider to explicitly link organ dysfunction to sepsis. A CDS should send a query to clarify if the AKI is a manifestation of the sepsis, using language such as 'acute kidney injury due to sepsis'.
Question 5: A patient is admitted for sepsis. If the source of the infection is known (e.g., pneumonia), how should the diagnoses be sequenced?
- Sequence the localized infection first, followed by the code for sepsis.
- Sequence the code for sepsis first, followed by the code for the localized infection. (Correct answer)
- Only the code for sepsis should be reported.
- It does not matter which code is sequenced first.
Correct answer: Sequence the code for sepsis first, followed by the code for the localized infection.
Per official coding guidelines, if the reason for admission is sepsis and a localized infection, the systemic infection (sepsis) should be sequenced first. The localized infection (e.g., pneumonia) is sequenced as a secondary diagnosis.
Question 6: The term 'urosepsis' is documented in the progress notes. What is the most appropriate action for the CDS?
- Code for sepsis, as it is clearly documented.
- Code for urinary tract infection, as that is the implied source.
- Query the provider to clarify the specific diagnosis (e.g., UTI, sepsis). (Correct answer)
- Ignore the term as it is not a valid diagnosis.
Correct answer: Query the provider to clarify the specific diagnosis (e.g., UTI, sepsis).
'Urosepsis' is a nonspecific term that does not have a corresponding ICD-10-CM code. The CDS must query the provider for clarification, asking if the patient has a urinary tract infection, sepsis, or both, based on the clinical indicators present.
Free CCDS Sepsis Criteria and Documentation (Sepsis-3) Questions and Answers 1
According to the Sepsis-3 consensus definition, sepsis is best described as: